Abortion Surveillance -- United States, 1995

Division of Reproductive Health
National Center for Chronic Disease Prevention and Health Promotion

Abstract

Condition: Since 1990 (i.e., the year in which the number of
abortions was
highest), the annual number of abortions in the United States has
decreased
by 15%.

Reporting Period Covered: This report summarizes and reviews
information
reported to CDC regarding legal induced abortions obtained in the
United
States during 1995.

Description of System: For each year since 1969, CDC has compiled
abortion
data received from 52 reporting areas: 50 states, the District of
Columbia,
and New York City.

Results: In 1995, a total of 1,210,883 legal abortions were
reported to
CDC, representing a 4.5% decrease from the number reported for
1994. The
abortion ratio was 311 legal induced abortions per 1,000 live
births, and
the abortion rate was 20 per 1,000 women aged 15-44 years, the
lowest ratio
and rate recorded since 1975. Women who were undergoing an abortion
were
more likely to be young, white, and unmarried; most were obtaining
an
abortion for the first time. Approximately half of all abortions
(54%) were
performed at less than or equal to 8 weeks of gestation, and
approximately
88% were performed before 13 weeks. Approximately 16% of abortions
were
performed at the earliest weeks of gestation (less than or equal to
6
weeks), approximately 17% at 7 weeks of gestation, and
approximately 21% at
8 weeks of gestation. Few abortions were provided after 15 weeks of
gestation -- approximately 4% of abortions were obtained at 16-20
weeks,
and 1.4% were obtained at greater than or equal to 21 weeks.
Younger women
(i.e., women aged less than or equal to 24 years) were more likely
to
obtain abortions later in pregnancy than were older women.

Interpretation: Since 1990, the number of abortions has declined
each year.
Since 1987, the abortion-to-live-birth ratio has declined; in 1995,
it was
the lowest recorded since 1975. This decrease in the abortion ratio
reflects a trend that a lower proportion of pregnant women obtain
induced
abortion.

Actions Taken: The number and characteristics of women who obtain
abortions
in the United States should continue to be monitored so that trends
in
induced abortion can be assessed, efforts to prevent unintended
pregnancy
can be evaluated, and the preventable causes of morbidity and
mortality
associated with abortions can be identified and reduced.

INTRODUCTION

In 1969, CDC began abortion surveillance to document the
number and
characteristics of women obtaining legal induced abortions, to
monitor
unintended pregnancy, and to assist efforts to identify and reduce
preventable causes of morbidity and mortality associated with
abortions.
This report is based on abortion data for 1995 provided to CDC's
National
Center for Chronic Disease Prevention and Health Promotion,
Division of
Reproductive Health.

METHODS

For 1995, CDC compiled data from 52 reporting areas: 50
states, the
District of Columbia, and New York City. The total number of legal
induced
abortions was available from all reporting areas; however, not all
of these
areas collected information regarding the characteristics of women
who
obtained abortions.

The availability of information about characteristics of women
who
obtained an abortion in 1995 varied by state. Most states (42
states, the
District of Columbia, and New York City) collected and reported
abortion
data by age of the woman, whereas only 21 states, the District of
Columbia,
and New York City collected and reported adequate abortion data by
Hispanic
ethnicity. In the "Results" section of this report, all of the
percentage
data for each characteristic represent known characteristics
without
redistribution of the unknowns. States were excluded from the
analysis if
data regarding a given characteristic were unknown for greater than
15% of
women (Table_3, Table_4, Table_5, Table_6,
Table_7,
Table_8, Table_9, Table_10, Table_11, Table_12,
Table_13).

For 48 reporting areas, data concerning the number and
characteristics
of women obtaining legal induced abortions were provided by the
central
health agency *; for the other four areas, data were provided from
hospitals and other medical facilities. Because information
concerning the
residence of women who obtained abortions was not available from
some
states, the procedures were reported by the state in which they
were
performed. However, for two reporting areas (i.e., District of
Columbia and
Wisconsin) occurrence data were unavailable.

For analysis by age, women who obtained legal induced
abortions were
grouped by 5-year age groups. Both ratios (i.e., the number of
abortions
per 1,000 live births per year) and rates (the number of abortions
per
1,000 women per year) are presented by age group in this report.
Ratios
were calculated by using the number of live births provided by each
state's
central health agency (except where noted), and rates were
calculated by
using the number of women reported in special unpublished
tabulations
provided by the U.S. Bureau of the Census. Because almost all (94%)
abortions among women aged less than 15 years in 1988 (the most
recent year
for which exact age data were available) occurred among those aged
13-14
years (1), the population of women aged 13-14 years was used as the
denominator for calculating abortion rates for women aged less than
15
years. Rates for women aged greater than or equal to 40 years were
based on
the number of women aged 40-44 years, whereas rates for all women
who
obtained abortions were based on the population of women aged 15-44
years.

Race was categorized by three groups (i.e., a} white, b}
black, and c}
all other races) or two groups (i.e., a} white and b} black and all
other
races). "Other" races included Asian/Pacific Islander, American
Indian,
Alaska Native, and women classified as "other" race.

In 1990, data regarding Hispanic ethnicity were first
available on
abortion reports submitted to CDC by central health agencies. As in
previous reports, Hispanic ethnicity and race were evaluated
separately,
and rates and ratios are presented by Hispanic ethnicity and race.

Marital status was reported as either married (which included
women
who were married or separated) or unmarried (which usually included
those
who were never married, divorced, or widowed). Reporting of marital
status
differed somewhat by state, particularly for the data used as
denominators
to calculate abortion ratios by marital status; therefore, abortion
ratios
by marital status should be interpreted cautiously.

Most areas (38 of 40) that reported adequate data on week of
gestation
at the time of abortion also reported procedures obtained at less
than or
equal to 6, 7, and 8 weeks of gestation. Gestational age (in weeks)
at the
time of abortion was reported by most areas from estimates derived
from the
time elapsed since the woman's last menstrual period. In 18 states
in 1995,
gestational age was reported on the basis of the physician's
estimate for
each reported abortion or when information regarding the last
menstrual
period was missing or illogical. Physician's estimates for
gestational age
also could have included information from the clinical examination,
as well
as the time elapsed since the last menstrual period.

RESULTS

In 1995, a total of 1,210,883 legal induced abortions were
reported to
CDC, representing a 4.5% decrease from the number reported for 1994
(2)
(Table_1). In contrast, from 1970 through 1982, the reported
number of
legal abortions in the United States had increased every year
(Table_2;
Figure_1); the largest percentage increase occurred from 1970
to 1971.
From 1976 through 1982, the annual increase declined and reached a
low of
0.2% during 1980-1981 and during 1981-1982. From 1983 through 1990,
the
number of abortions increased again, although moderately (less than
or
equal to 5% from year to year). However, since 1990, the annual
number of
abortions has decreased each year.

The national legal induced abortion ratio increased from 1970
to 1980,
peaked at 364 per 1,000 live births in 1984, and began to decline
steadily
in 1987, from 356 per 1,000 to 311 per 1,000 in 1995 (Figure_1;
Table_2). The national legal induced abortion rate increased
from five
abortions per 1,000 women aged 15-44 years in 1970 to 25 per 1,000
in 1980.
From 1981 through 1992, the rate remained stable at 23-24 abortions
per
1,000 women, then declined to 22 in 1993, to 21 in 1994, and to 20
in 1995.

In 1995, as in previous years, most legal induced abortions
were
performed in California, New York City, Texas, and Florida; the
fewest were
performed in Wyoming, Idaho, South Dakota, and North Dakota
(Table_3)
(2). For women whose state of residence was known, approximately
92% had
obtained the abortion within the state in which they resided. The
percentage of abortions obtained by out-of-state residents ranged
from
approximately 53% in the District of Columbia to less than 1% in
Hawaii.
For 1995, nine reporting areas could not provide data concerning
abortions
obtained by out-of-state residents.

Women aged 20-24 years obtained approximately one third (32%)
of all
abortions; women aged less than 15 years obtained less than 1% of
all
abortions (Table_4). Abortion ratios were highest for the
youngest
women (i.e., 667 abortions per 1,000 live births for women aged
less than
15 years and 399 per 1,000 for women aged 15-19 years) and for the
oldest
women (387 per 1,000 live births for women aged greater than or
equal to 40
years). The ratio was lowest for women aged 30-34 years (165 per
1,000 live
births) (Figure_2; Table_4). Among adolescents, the
abortion ratio
was highest for those aged less than 15 years and lowest for those
aged 19
years (Table_5).

In contrast to abortion ratios, abortion rates were highest
for women
aged 20-24 years (37 abortions per 1,000 women) and lowest for
women at the
reproductive-age extremes (i.e., two per 1,000 women aged less than
15
years and two per 1,000 women aged greater than or equal to 40
years)
(Table_4).

For women in most age groups, the abortion ratio increased
from 1974
through the early 1980s and declined thereafter, particularly for
the
youngest and oldest reproductive-aged women (Figure_3).
Abortion ratios
for women aged less than 15 years have been and remain higher than
those
for the other age groups. From 1994 to 1995, the abortion ratio
decreased
for women aged less than 15 and 15-19 years and was the lowest ever
recorded for these age groups. The abortion ratio for women aged
20-34
years (i.e., the group with the highest fertility rate) (3) has
remained
stable since the mid-1980s.

During 1995, approximately 53% of reported legal induced
abortions
were obtained at less than or equal to 8 weeks of gestation, and
approximately 86% were obtained at less than 13 weeks
(Table_6).
Approximately 15% of abortions were performed at the earliest weeks
of
gestation (less than or equal to 6 weeks), approximately 17% at 7
weeks,
and approximately 21% at 8 weeks (Table_7). Few abortions were
provided
after 15 weeks of gestation -- approximately 4% of abortions were
obtained
at 16-20 weeks, and 1.4% were obtained at greater than or equal to
21 weeks
(Figure_4; Table_6).

Almost all (98%) abortions were performed by curettage and
less than
1% by intrauterine saline or prostaglandin instillation
(Table_8).
Hysterectomy and hysterotomy were used in only a few cases: less
than 0.01%
of abortions were performed by using these methods.

Approximately 58% of women who obtained legal induced
abortions were
white (Table_9). The abortion ratio for black women was 534 per
1,000
live births; this was approximately 2.5 times the ratio for white
women
(204 per 1,000 live births). The abortion ratio (335 per 1,000 live
births)
for women of other races was approximately 1.6 times the ratio for
white
women. In addition, the abortion rate for black women (31 per
1,000) was
approximately 2.5 times the rate for white women (12 per 1,000
women).

Twenty-one states, the District of Columbia, and New York City
**
reported data concerning the Hispanic ethnicity of women who
obtained legal
induced abortions (Table_10). The percentage of abortions
obtained by
Hispanic women in these reporting areas ranged from less than 1% in
several
states to approximately 44% in New Mexico. For Hispanic women in
these
reporting areas, the abortion ratio was 265 per 1,000 live births
--
slightly lower than the ratio for non-Hispanics in the same areas
(280 per
1,000). However, the abortion rate per 1,000 Hispanic women (20 per
1,000
women) was greater than the rate per 1,000 non-Hispanic women (15
per
1,000).

Seventy-nine percent of women who obtained abortions were
unmarried
(Table_11). The abortion ratio for unmarried women was
approximately
nine times the ratio for married women (650 versus 76 abortions per
1,000
live births).

Approximately 45% of women who obtained legal induced
abortions had
had no previous live births, and approximately 89% had had two or
fewer
previous live births (Table_12). The abortion ratio was highest
for
women who had had three previous live births and lowest for women
who had
had one previous live birth.

In 1995, of women who obtained an abortion, 54% of women
obtained an
abortion for the first time. Approximately 17% of women had had at
least
two previous abortions (Table_13).

The age distribution of women who obtained a legal abortion
differed
slightly by race (Table_14). However, for women of black or
other
races, the percentage who were aged less than 15 years, although
small
(1.1%), was nearly twice the percentage for white women (0.6%). The
percentage of women of black or other races who were unmarried
(83%) also
was slightly higher than the percentage of white women (78%). Few
differences were found by age and Hispanic ethnicity
(Table_15). Of
those women who had obtained an abortion, a slightly higher
percentage of
non-Hispanic women were unmarried in comparison with Hispanic
women.

Most (approximately 86%) women who obtained an abortion had
their
procedure during the first 12 weeks of pregnancy; however,
adolescents
(i.e., women aged less than or equal to 19 years) were more likely
than
older women to obtain abortions later in pregnancy (Table_16
and
Table_17). The percentage of women who obtained an abortion
early in
pregnancy (i.e., at less than or equal to 8 weeks of gestation)
increased
with age, and the percentage who obtained an abortion late in
pregnancy (at
greater than or equal to 16 weeks of gestation) decreased with age
for
women up to 25-29 years of age and remained stable for women in
older age
groups (Figure_5; Table_16). Black women were more likely
to obtain
an abortion later in pregnancy than were white women or women of
other
races (Table_16 and Table_17). Of all women who obtained an
abortion, Hispanic women were slightly more likely than
non-Hispanic women
to have had an abortion at less than or equal to 8 weeks of
gestation and
less likely to have had an abortion late in pregnancy (greater than
or
equal to 21 weeks), the overall differences between Hispanic and
non-Hispanic women in the timing of abortions were minimal
(Table_16).

More than 99% of abortions at less than or equal to 12 weeks
of
gestation were performed by using curettage (primarily suction
procedures)
(Table_18). After 12 weeks of gestation, the most frequently
used
procedure also was curettage, although it usually was reported as
dilatation and evacuation (D&E). Intrauterine instillations
involved the
use of saline or prostaglandin; these procedures were used
primarily at
greater than or equal to 16 weeks of gestation.

DISCUSSION

Since 1990 (i.e., the year in which the number of abortions
was
highest), the annual number of abortions in the United States has
decreased
by 15% (Table_2) (2,4). In 1995, the national
abortion-to-live-birth
ratio was the lowest recorded since 1975 (5). The abortion ratio
had
increased steadily from 1970 through 1980, decreased slightly
during
1981-1983, increased to its highest level in 1984, then remained
fairly
stable until 1987, before beginning to decline each subsequent year
(Table_2; Figure_1). The decreasing abortion ratio resulted
from a
lower proportion of pregnant women who had obtained an abortion in
recent
years. Factors that may contribute to this effect include
attitudinal
changes concerning abortion and/or carrying unplanned pregnancies
to term
and the decreased number of unintended pregnancies in recent years
(6).

In addition, in 1995, the national abortion rate was the
lowest
recorded since 1975 (5). This decline in the abortion rate probably
reflects the decreasing rate of unintended pregnancies; reduced
access to
abortion services; and changes in contraceptive practices,
including an
increased use of contraception, particularly an increased use of
condoms
among young women (6-9). In this report, the induced abortion rate
in the
United States was higher than rates reported for Australia and
Western
European countries and lower than rates reported for China, Cuba,
Eastern
European countries, and the Newly Independent States of the former
Soviet
Union (10). Also, a recent study from Canada for 1995 reported a
legal
induced abortion rate that was approximately 26% lower than the
rate in the
United States (15.5 abortions per 1,000 women aged 15-44 years
versus 21
per 1,000, respectively) and an abortion-to-live-birth ratio
approximately
12% lower than the ratio in the United States (282 per 1,000 live
births
versus 321 per 1,000, respectively) (11). Abortion and birth rates
for
teenagers are higher in the United States than in most Western
European
countries and some Eastern European countries (12).

As in previous years, the abortion ratio in 1995 varied
substantially
by age (2). Although the ratio was highest for adolescents, the
percentage
of legal induced abortions obtained by women aged less than or
equal to 19
years has decreased since the mid-1980s (i.e., from 26% in 1984 to
22% in
1990 and to 20% in 1992) and has remained at that level (4,13).
Since 1980,
the abortion ratio has declined for most age groups -- particularly
for
those at the age extremes -- women aged less than or equal to 19
years and
greater than or equal to 35 years. In 1995, the abortion ratio for
adolescents (i.e., aged less than 15 and 15-19 years) was the
lowest ratio
CDC had ever recorded for these age groups. Other studies have
indicated a
decrease in teenage pregnancies from 1992 to 1995 and a decrease in
teenage
birth rates from 1994 to 1995 (3,14).

In 1995, as in previous years, the abortion ratio for black
women was
approximately twice the ratio for white women; this differential
has
increased since 1986. In addition, the abortion rate for black
women was
approximately 2.5 times the rate for white women. Race-specific
differences
in legal induced abortion ratios and rates may reflect differences
in
factors such as socioeconomic status, contraceptive use, incidence
of
unintended pregnancies, and access to family-planning and
contraceptive
services.

The abortion-to-live-birth ratio for Hispanic women during
1995 was
slightly lower than that for non-Hispanic women. Other published
reports
indicate that pregnant Hispanic women are less likely than pregnant
non-Hispanic women to obtain an abortion (19). However, the
abortion rate
per 1,000 Hispanic women was higher than the rate for non-Hispanic
women,
which is consistent with several other studies (19-20). For women
in all
age groups, fertility was higher for Hispanic than for non-Hispanic
women
(3).

In 1995, a total of 36 states, including the District of
Columbia and
New York City, reported Hispanic ethnicity of women who obtained
abortions.
Because of concerns regarding the completeness of such information
(greater
than 15% unknown data) regarding Hispanic ethnicity in some states,
data
from only 21 states, the District of Columbia, and New York City
were
evaluated to determine the number and percentage of abortions
obtained by
women of Hispanic ethnicity in 1995. These geographical areas
represent
approximately 38% of all reproductive-aged Hispanic women in the
United
States in 1995 (CDC, unpublished data). One published report of a
study
that used abortion data obtained from CDC also suggests that the
number of
Hispanics obtaining abortions may be underestimated (20). Thus, the
number,
ratio, and rate of abortions for Hispanic women in this report
might not be
representative of the overall Hispanic population in the United
States
(i.e., these data might reflect utilization of abortion services
only in
the areas included in this analysis).

Since 1980, the percentage distribution of abortions by
gestational
age has been stable, with slight percentage increases toward the
earliest
and latest gestational ages and slight percentage decreases for
abortions
performed at 8, 9-10, and 11-12 weeks. Since 1990, there has been
an
increase in the percentage of abortions performed at the early
weeks of
gestation (i.e., less than or equal to 6 and 7 weeks). Recently,
there has
been an increased interest in surveillance for abortions performed
late in
pregnancy (i.e., greater than or equal to 21 weeks) (21).

Since 1992, most reporting areas have reported abortions by
gestational age, in weeks of gestation, for abortions performed at
less
than or equal to 6, 7, and 8 weeks (2). These data will assist in
monitoring trends in legal abortions as new medical (nonsurgical)
methods
of terminating pregnancy are implemented because these new methods
are used
primarily to terminate pregnancies at less than or equal to 8 weeks
of
gestation (22-25). During 1994-1995, approximately 2,000 women in
the
United States aged greater than 18 years participated in clinical
trials
testing mifepristone, a medication used for medical (nonsurgical)
abortion
(26). This medication has not yet been fully approved by the Food
and Drug
Administration for use and distribution in the United States
(Population
Council, personal communication, 1998). However, other medications
(e.g.,
methotrexate and misoprostol) are currently being used to perform
early
medical (nonsurgical) abortions (24-25).

In this and previous reports, age was inversely associated
with timing
of abortion (2,27,28). As in previous years, younger women were
more likely
to obtain an abortion later in gestation than were older women.

From 1972 to 1995, the percentage of abortions performed by
curettage
(which includes D&E) increased from 89% to 99% (Table_1), and
the
percentage of abortions performed by intrauterine instillation and
by
hysterectomy and hysterotomy declined sharply (from 10% to 0.5% and
from
0.6% to less than 0.01%, respectively). From 1974 through 1995, the
percentage of second-trimester abortions performed by D&E increased
from
31% to 94%; the percentage of second-trimester abortions performed
by
intrauterine instillation decreased from 57% to 4% (29). The
continued
reliance on D&E probably has resulted from the lower risk for
complications
associated with the procedure (30,31).

The numbers, ratios, and rates of abortion from this analysis
are
conservative estimates because the numbers of legal abortions
reported to
CDC for 1995 were probably lower than the numbers actually
performed.
Totals provided by central health agencies may be lower than those
obtained
by direct surveys of abortion providers (32). For example, the
total number
of abortions reported to CDC for 1992 was approximately 11% lower
than that
reported for 1992 *** by The Alan Guttmacher Institute, a private
organization that directly contacts abortion providers to obtain
information concerning the total number of abortions performed (8).
In
addition, not all states collected and/or reported information
(e.g., age,
race, and gestational age) concerning women obtaining a legal
induced
abortion during 1995; therefore, the numbers, percentages, rates,
and
ratios derived from this analysis may not be representative of all
women
who obtained abortions in that year.

Despite these limitations, findings from ongoing national
surveillance
for legal induced abortion are used for several purposes. First,
data from
abortion surveillance are used to identify characteristics of women
at high
risk for unintended pregnancy. Second, ongoing annual surveillance
is
essential to monitor trends in the number, ratio, and rate of
abortions in
the United States. Third, statistics on the number of pregnancies
ending in
abortion are used in conjunction with birth and fetal death
statistics to
estimate pregnancy rates (e.g., pregnancy rates among teenagers)
(1) and
other outcome rates (e.g., the rate of ectopic pregnancies per
1,000
pregnancies). Fourth, abortion and pregnancy rates can be used to
evaluate
the effectiveness of family-planning programs and programs for
preventing
unintended pregnancy. Fifth, ongoing surveillance provides data for
assessing changes in clinical practice patterns related to abortion
(e.g.,
longitudinal changes in the types of procedures and trends in
gestational
age at the time of abortion). Finally, abortion data are used as
the
denominator in calculating abortion morbidity and mortality rates
(2).

Induced abortions usually are linked to unintended
pregnancies, which
often occur despite use of contraception (20,33,34). In 1995, data
from the
National Survey of Family Growth (NSFG) indicated that
approximately 31% of
live births were associated with unintended pregnancy (i.e., either
mistimed or unwanted at conception) (6). Unintended pregnancy is
not a
problem just for adolescents, unmarried women, or for poor women;
it is a
pervasive public health problem that spans all groups of women (6).

In a study of abortion patients conducted during 1994 and
1995,
researchers found that 58% of patients reported that they
"currently used"
contraception during the month of their last menstrual period;
however,
their use of contraception may have been inconsistent or incorrect
(20).
Researchers conducting the most recent NSFG have estimated that in
1995,
approximately 29% of U.S. women who used oral contraceptives as
their only
contraception and who had intercourse during the 3 months before
their NSFG
interview reported that they missed a birth control pill one or
more times
during the 3 months. In addition, approximately 33% of U.S. women
who were
using only coitus-dependent contraceptive methods **** during the 3
months
before the interview used these methods inconsistently (6).
Therefore,
education regarding improved contraceptive use and practices, as
well as
access to and education regarding safe, effective, and low-cost
contraception and family-planning services, may help reduce the
incidence
of unintended pregnancy and, therefore, may reduce the use of legal
induced
abortion in the United States (35,36).

Recently passed welfare-reform legislation -- the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996
***** -- has
increased the interest in accurate state-based surveillance for
induced
abortion. In addition, some states have recently instituted
programs that
emphasize the prevention of unintended pregnancy, particularly
among
adolescents. To help guide these efforts, an ongoing, accurate
assessment
of induced abortion is needed in all states to determine the number
and
characteristics of women who obtain these procedures.

Additional statistical and epidemiologic information about
legal
induced abortions is available from CDC's automated Reproductive
Health
Information System. This system provides information by fax, voice
recordings, or mail; telephone (888) 232-2306. Copies of MMWR
reports
containing statistical and epidemiologic information about
abortions also
can be obtained through the CDC World-Wide Web site at
(http://www.cdc.gov).

* Includes state health departments and the health departments of
New York
City and the District of Columbia.

** After excluding states for which data was unknown for less than
15% of
women who obtained an abortion.

*** The most recent year for which The Alan Guttmacher Institute
reported
data.

**** Coitus-dependent contraceptive methods include male or female
condoms,
diaphragm, sponge, cream, jelly, or other methods that must be used
at the
time intercourse occurs.

***** Section 103 of P.L. 104-193 provides for additional welfare
funding
for as many as five states if a) the birth rate of infants to unwed
mothers
is decreased and b) the rate of induced pregnancy terminations is
less than
the rate for 1995 (the baseline year).

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